The main tenets of care decision making are these – that the individual’s wishes should be respected, and that a choice is available.

When does someone need care?

One of the most difficult issues for many people is recognising and accepting that they can no longer safely look after themselves. Often it is the observation and intervention of others which triggers this recognition. Sadly, all too often, it takes a crisis to precipitate acceptance – for example, a fall at home, or some other accident which causes a reappraisal of one’s faculties. In many cases, sheer willpower and determination to remain independent can overcome these obstacles, but at some time, a point of decision will arise.

Old age brings with it a number of general ailments and syndromes which conspire to restrict what we think of as our daily routine. One does not need to be diagnosed with Parkinson’s, Alzheimer’s or other degenerative condition in order to suffer limitations on normal activities. Stairs may become an insuperable problem. Housework and gardening may be beyond one’s resources. Standards of housekeeping, of personal hygiene and especially of proper diet slowly fall away.

Visiting relatives, especially the occasional ones, are often the initiators of change. The Christmas visit brings with it the realisation that the elder cannot do things – evidenced often enough by conditions in the house, and maybe more seriously by unchecked health issues. Once this realisation has sunk in, it is time to contemplate taking professional advice.

Care At Home

For many people, the thought of leaving home is unbearable. Apart from the emotional wrench, one’s ability and willingness to tolerate others in close proximity may be reduced, so the idea of going into “a Home” is not appealing.

For a number of years now, the authorities have actively encouraged older people to try to stay in their own homes for as long as possible. Social Services departments are generally well disposed towards assisting or at least advising in the provision of care services at home. Examples of this are “meals on wheels”, or visiting qualified carers who are trained to supervise personal care such as getting up, washing and dressing.

The process starts with an assessment made by a Social Services Care Manager. This is a formal, standardised check which leads to recommendations as to the type and extent of care to be provided. Considerations of payment for this care are discussed under the section entitled “How Is Care Paid For”, later in this article.

Keeping people in their own homes is a mixed blessing. It is questionable whether their overall well being is best served by this policy. Without the regular contact and stimulation of others, health can deteriorate faster. Lonely hours in between carer visits must be endured. Contract carers may not be reliable in their attendance, which may mean that the true burden of responsibility rests with relatives – whose own quality of life may be seriously damaged by this duty of care. Every day, the relative is waiting for the call to attend because of some failure of the system, instead of being able to visit and give their love and attention in a relaxed way, safe in the knowledge that the elder is receiving 24 hour care from the sanctuary of a good care home.

When people are eventually forced to take places in care homes, their condition is worse, which places more of a burden upon the home. It also means that the ability of the elderly person to adapt to the new environment is much lower, often resulting in unnecessarily premature collapse and death.

On a broader economic note, there are also questions about the wisdom of keeping elderly people occupying houses which may be desperately needed by a first time buyer market. The meteoric rise of property prices means that further gains made by hanging on will be eroded by inheritance tax – whereas prudent re-investment supervised by a competent professional could protect the inheritance and provide care funding at the same time. Too many people act too late, and the only winner is the tax man.

Retirement and Sheltered Accommodation

If the original family home is proving too much of a burden, yet all other forms of self-reliance are still viable, the option exists to move into purpose-built or adapted housing which specifically suits the elderly. These homes are usually smaller in overall size, and are built on one floor with no requirement for access by stairs. Such homes are often marketed with the assistance of trading the previous home against them to reduce the distress and inconvenience of change.

An advance on Retirement housing is the Sheltered Home, where full independence is maintained, but where there is a resident warden available on call at any time to render assistance.

“I’m not going into a Home”

When independence becomes unsafe or unworkable, the next resort is to a traditional Rest or Nursing Home.

What is this “Home” to which the old saw refers? An institution, presumably – a scrap yard where people go to wait for God? Not anymore. In the past 10 years, Rest and Nursing Homes in the UK have undergone substantial change for the better. Cases of malpractice and abuse occasionally hit the headlines, but these are relatively rare. The vast majority of Homes are owned and run by vocationally dedicated people, who do so for a legitimate profit – but who would not choose that life style were it for profit alone.

In its own view, the Care Home sector has been somewhat hounded and blighted by Government policy since the early 1990s. Many of the problems are in fact shared by all forms of small and medium sized businesses. Care Homes have been subjected to restriction of Government funding, which is the single most unfortunate aspect of the current situation in which there is a national shortage of beds in the independent sector – the public (council) sector having mainly abandoned provision due to rising costs.

Rest Home or Nursing Home – Care Needs Categories

There are two choices of Home type, and unless money is no object, the choice is usually dictated by the assessment of care needs. As stated previously, this assessment will be undertaken on request by the Local Authority Social Services department, and it is likely that the General Practitioner will also be involved (in fact, the GP often starts the process).

The choice will be made to ensure that the person gets the attention and care that they need. There is no need to enter a nursing home if the attention of a qualified Registered General Nurse (RGN) is not needed – to do so is to pay beyond reason.

Assessments of care needs are made based upon a system of Assessment Levels, ranging from Low to High Dependency Residential to Nursing. Low Dependency Residential is someone who can do most things for themselves, and who are generally continent and mobile. They are in the Home simply by choice, like living in a hotel, or maybe because they need some encouragement to maintain personal standards or health through proper diet. On their own, they would deteriorate rapidly, but with the support of a care staff, they can retain a good quality of life, and will make and sustain friendly relationships with others in the Home.

The next level describes someone who may have mobility problems, possibly be partially incontinent, and probably needs prompting to do the right things in respect of personal hygiene and feeding. The possibility of early dementia exists, if not already diagnosed or evidenced by the loss of ability to maintain standards while alone.

The highest level of dependecy for residential clients is characterised by probable double incontinence, recognisable dementia up to moderate confusion (but not antisocial behaviour), problems with mobility and a general need to be prompted or assisted with most things.

Nursing is reserved for people who may have some or all of the previous high dependency residential conditions, and who also need full time medical supervision by qualified nursing staff (as opposed to qualified care assistants).

There are special categories for people with severe dementia, especially where this manifests itself as a tendency to wander or show antisocial behaviour. There are Homes which are Elderly Mentally Ill (EMI) qualified, some of them with secure facilities.

Choosing a Home

When choosing a Home, and when the field is open to personal selection, care should be taken to try to compare Homes through the eyes of the elderly person, perhaps to the exclusion of some of one’s own views and prejudices. For example, a large, spacious room may sound like a good idea, but can be an insurmountable obstacle for a person with mobility problems.

En suite toilets and hand basins are popular, but there is little point in insisting upon full en suite bath facilities if all bathing is going to be supervised by Care Staff who can conduct the person to a central bathroom with better facilities such as (expensive) bath hoists or hydraulic bath seats.

The Home should be able to cater for any special dietary needs or preferences. A small Home may offer the best warmth of close care, but it is probably unrealistic to expect an a la carte menu with three choices of main dish every day in such a Home. Perhaps late afternoon high tea is to individual order. Within the bounds of medical constraints, a Resident should be able to request small things like hot drinks at any time.

In the interests of safety, a non-smoking policy is a good thing – because the single most common cause of domestic fires where elderly people are concerned is falling asleep while smoking. It is not easy for Homes to accommodate pets, but in consolation, there may be some resident cats or dogs who take full advantage of any willing lap or favour!

Experienced Inspectors will privately admit that they can tell a good Home within seconds of opening the front door. This faculty is available to the untrained prospective client too. It is about the feel of the place - the manner in which the Home’s Manager and Care Staff approach Residents, the absence of tension, maybe a fresh, clean airiness in the atmosphere. Visitors might be offered tea and biscuits on arrival. Visiting policies will be open ended. The Home will respect the person’s privacy - and their degree of desire to integrate or be left alone.

All the formal paperwork of inspection and regulation cannot tell you about the true quality of care. A Home may meet all the standards, yet seem to some people like an institution, an emotionally barren wasteland. However, the introduction of uniform standards and the consequent rationalisation of less well run homes have both served to improve confidence for would-be residents. Homes which have survived have done so because they are better run. Any proprietors who were in it only for the money would have been weeded out; leaving a majority of reliable establishments whose reputation is intact and hard-won.

Standards are now managed by the National Care Standards Commission, and the reports on individual homes are available from the NCSC, or indeed should be provided on demand by the Home. There will be a “Service User Guide” which clearly states what the Home can provide, and this should be compared to the assessed needs of the individual before agreeing a placement.

Assessment and Placement Policies

In general, Care Managers no longer place Low Dependency people in Care Homes unless it is at the persons own explicit request. The dogma says that they should stay in their own homes and receive appropriate domiciliary care from agency staff. This is driven primarily by financial constraints, because Local Authorities have either been starved of central funds or may have chosen to allocate Council Tax Payers money elsewhere other than in elderly care provisions.

Ten years ago, any Higher Dependency people would have been in nursing homes. The policy of starving out Rest Homes by denying placement of Lower dependency people caused many Rest Homes to adapt to handle Higher Dependency people, accepting heavy case loads at unrealistically low fee levels. The result for Local Authorities and Government was to save money at the expense of those who could afford to pay and whose capital exceeded the means tested limits for public assistance.

In general then, Higher Dependency people will be placed in Rest Homes, where there is no nursing care available, and where medical supervision is carried out by the General Practice. The highest dependencies will be in Nursing Homes.

Some Rest Homes operate a care for life policy, in which they will attempt to care for a Resident to the end (subject to medical expedience). This has advantages from a settlement and emotional viewpoint both for the Resident and for their relatives. It is well known that moving a frail elderly person carries with it a significant risk of deterioration and often premature death.

How Care Is Paid For

Placement in Care is means tested by Government. The job of funding assessment and provision has been delegated to Local Authorities. If a person has savings and assets amounting to over £19,000 (2003 figure), they will receive no assistance except possibly advice on placement from a Social Services Care Manager.

In the case of wholly private funding, the individual and their relatives or representatives are free to go out and purchase care privately in any manner they see fit. However, it will be important to make a judgment as to how long these funds will last in relation to life expectancy it would be unfortunate for someone to have to move down market at a late stage because the public funding that becomes necessary will not stretch to the class of living to which they had become accustomed. As was said earlier, a move of Home in the more advanced years is often followed by an early demise.

All income from state and private pensions and other sources is assessed according to statutory guidelines. When public funding assistance is allowable, the Local Authority will arrange the contract for the purchase of care services with the designated care home. Contract fee levels will have already been agreed - or rather dictated - by the Authority, and are linked to the Level of Care assessed. Typically, for a Shire County, the 2003-04 weekly figures are as follows, with higher rates common in costly areas such as London:

• Lowest Dependency £238
• Low Dependency £292
• Higher Dependency £315
• Nursing £360 plus the Primary Care Trust provision

It is now an accepted fact that these prices are in the region of £70-£100 per week below the minimum economic levels at which homes can afford to operate. Consequently, most homes have adopted a policy of trying to bias their intake towards private clients, where the fees range from £350 to over £700 a week depending upon the Level of care and the quality and location of the Home.

It is this under funding, coupled with the practical, financial and emotional burdens of legislation and standards – and the meteoric rise in freehold property values – which have caused so many homes to sell out. The fact is that Government rightly wants to raise standards, but is unwilling or unable to pay for it. The assets and inheritances of people are being systematically stripped out over the years to fill the gap.

If there is a house to sell, and therefore the assets probably exceed the threshold for Local Authority funding, there is a provision in law to assist with the bridging of care costs during time taken to sell. The Authority is required to provide funding for up to 12 weeks or until the time when the house sale completes, whichever is the shorter. During this time, the Authority will use its standard funding and placement methods to assist in the purchase of care. The bridging finance is the same as when the funding is permanent, that is to say the person must pay up their pensions and allowances to help pay for the place in the Home. If there is a relative living in the property, who wishes to remain there, special provisions apply.

So in a typical public funds assisted placement, the person receiving care will normally be expected to pay up their retirement pension and any income support or attendance allowance which they are getting. They will be allowed around £16 a week for personal expense items not usually covered in Rest or Nursing Homes (such as newspapers, hairdressing and alcohol). The remainder of the Home’s fees, up to the contractually agreed fee level, will be paid directly to the Home by the responsible Local Authority.

It is worthwhile checking that all available allowances are being received. A person who is a borderline upper Level 2 or Level 3 and 4 may well qualify for Higher Rate Attendance Allowance. This can be around £50 per week and makes a useful contribution toward the cost of appropriate care.

If there is a requirement to pay above the contract fee level set by the Local Authority, as a result of the free choice of the person, or through election of their relative or representative, then the excess amount is referred to as a “top up”. The Local Authority rules dictate that any such top up must come from a third party – it cannot be paid from person’s own assets, because by definition, those assets will already have been accounted for in the assessment of funding requirements.

For this reason, an independent financial adviser may well suggest that arrangements should be made well ahead of the time when care may be needed to rearrange assets to optimise the outcome for the person and their relatives. Going back to the opening point about how difficult it is to face up to the need for full time care, it is often rather tricky to persuade an elderly person as to the wisdom of transferring and reorganising money for these purposes.

Summary

• Plan ahead for care even if you can’t bear the idea
• Get independent financial advice if there are assets over £20,000 involved such as the sale of a house
• Make sure funds are potentially available for the long stay
• Get the Local Authority Social Services to do an assessment of care needs
• Research the various Homes in the preferred locale
• Review the National Care Standards Commission report on the chosen Home(s)
• Listen to the advice of GPs and others in the Community such as Day Centre staff

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